Embed Size (px)
Citation preview
The Robert Jones & Agnes Hunt Orthopaedic and District Hospital NHS Trust
Oswestry, Shropshire SY10 7AG
Tel.01691 404000 Fax. 01691 404050 Website. www.rjah.nhs.uk
WR
ITING
, DE
SIG
N, P
RO
DU
CTIO
N: S
LOW
IK JA
ME
SO
N A
SS
OC
IATES
01952 728282
Leading the movement in excellence
NHS
Did You
Know?915 hips were replac
ed
at the hospital durin
g
the year.
The Trust is a specialist elective orthopaedic hospital. It is committed to providing the best possible care,
training and research in the field of musculo-skeletal medicine to benefit the people of England, Wales
and beyond.
It also provides elective non-orthopaedic services for the communities in and around Oswestry. The Trust
actively seeks to develop partnerships and clinical networks to enhance these objectives.
Sowing the seeds...
The Robert Jones & Agnes Hunt Orthopaedic and District Hospital NHS Trust Annual Report 2002/03NHS
...reaping the benefits
The Robert Jones and Agnes Hunt Orthopaedic and
District Hospital NHS Trust is preparing the ground
for a strong, healthy future.
As an international centre of excellence in
musculo-skeletal disorders, it aims to strengthen
areas that need a tighter focus and to improve still
further the things the hospital does well. This has
been a guiding principle since the hospital was
founded by the two visionary orthopaedics pioneers
Robert Jones and Agnes Hunt early in the last century.
This Annual Report describes how we are sowing
the seeds of continuous improvement, and how our
patients and the community we serve are already
reaping the rewards.
The Trust wants to be open with you about the way the
hospital is run, and all Board meetings are held in public.
Details of where and when they are held are regularly
advertised. We welcome comments on our publications
and activities. Please feel free to contact:
Jackie Daniel, Chief Executive
The Robert Jones And Agnes Hunt Orthopaedic
and District Hospital NHS Trust
Oswestry, Shropshire SY10 7AG
Telephone: 01691 404358
Fax: 01691 404050
E-mail: [email protected]
Website: www.rjah.nhs.uk
2
Purpose
The Trust Board is responsible for setting the overall
strategic direction of the Trust. It decides on policy, and
makes sure that the hospital continues to provide high
quality services and to be financially sound.
Membership
Members of the Trust Board during 2002/03:
Chairman: Michael Bolderston
Chief Executive: Jackie Daniel
Executive Directors:
Medical Director: Dr Josh Dixey
Director of Finance: Andrew Robinson
Director of Nursing: Maurya Cushlow (until Dec 2002)
Director of Estates and Facilities: Colin Plant
Director of Human Resources: Sarah Sheppard
Non-Executive Directors:
Nonna Woodward
Professor Peter Jones
Angela Vint
(Two vacancies to be filled 2003-4)
The Trust Board
3
Chairman’s Report..................4Chief Executive’s Report...........5Modern Matron........................6Paediatrics.............................6DayHospital/Rapid Response/Sheldon Ward..........................7Mid lands Centre for Spina lInjuries.....................................8Specialist nurses......................9Cancer Unit............................10Overseas patients..................10Occupational Therapy............11Physiotherapy........................11Human Resources.................12Theatres................................12Pharmacy...............................13Orthotics................................13Radiology...............................13Voluntary services..................14ORLAU/Torch Appeal.............14Research...............................15Life-long learning...................15Library/Institute of Orthopaedics.16Patient Access/Healthcarerecords..................................16Estates..................................17Hotel Services........................17Clinical Placements Facilitator....17Information governance.........18Clinical Audit..........................18Infection control.....................19Patient and public involvement...19Ludlow Ward.........................20Clinical activity........................20Contracts...............................21Financial report......................22
ContentsThe Chief Executive was appointed through an appointments
committee made up of the Trust Chairman, Chief Executive of
the NHS Executive West Midlands, and an external chief
executive assessor. The appointment is made on a permanent
basis, and may be terminated by the Trust Board. The same
appointments criteria apply to all board directors.
The Trust keeps a Register of Directors’ interests, and a
Hospitality Register. You can ask to see these.
Sub-committees
To help it do its job properly, the Board has a number of
formal sub-committees.
The Audit Committee is chaired by Nonna Woodward, and
includes Peter Jones and Angela Vint (all non-executive
directors). The committee asks the Finance Director, Chief
Executive and members of the Internal and Extemal Audit to
attend its meetings, held four times a year. It makes sure that
the Trust has adequate systems of internal control to safeguard
assets, avoid waste and inefficiency, produce reliable financial
information, and continuously seek value for money.
The Remuneration Committee decides the pay, benefits,
and terms and conditions for the executive directors. It
comprises the Chairman and non-executive directors. Pay
levels are determined by the Committee with reference to the
achievement of hospital and individual objectives and to salary
information from local and national comparitors.
Other sub-committees cover:
● Research and development
● Complaints
● Clinical Governance/Risk Management
● Charitable Funds
CIinical Governance and RiskManagement Committee
The Clinical Governance and Risk Management Committee
is chaired by Michael Bolderston, Board Chairman.
Membership includes the Chief Executive and Medical
Director. The aim of the committee is to monitor the
progress of plans for Clinical Governance, risk
prioritisation and continuous improvements in the
quality of care.
Working With Our Staff
The Trust has achieved the NHS Improving Working Lives
“Practice Standard” and is involving staff in devising and
implementing key initiatives. It has developed policies and
procedures with Trade Unions to ensure that staff are
supported. Most staff are employed on national terms and
conditions. However, those for Health Care Assistants and
Support Workers are locally determined.
Our new Chief Executive Jackie Daniel had only
just joined the Trust as the last Annual Report
appeared, so I am pleased to welcome her here.
I also want to thank her for steering the Trust through a
tempestuous 12 months. Jackie has worked hard to put
in place a clear strategy for the next three years, despite
daunting financial and organisational challenges.
One challenge concerns waiting lists, which we happily
embrace, because the targets they represent enable us
to show how good we are. The disparity between
English and Welsh waiting times causes some
difficulties, but we welcome and support investment
plans by our Welsh commissioners to close this gap.
We work on this and other issues with the Welsh
Assembly, as we work with English and Welsh local
authorities and other strategic partners to benefit our
patients.
We are actively pursuing public and private
investment to improve the state of our buildings and
Michael Bolderston
Chairman
Chairman’s Report
increase our capacity. We are proud of the quality
of our work, and want to go for more of it.
We are treating more patients, and our clinical
services keep improving. External audits and patient
surveys confirm the excellent standards of care,
dedication and expertise at the Trust. Huge credit is
due to all of our people for their contribution.
The other people deserving our deep gratitude are the
volunteers who are raising money for the new
therapeutic pool and the Torch appeal, who run
fund-raising events and who tirelessly provide services
and support for the hospital.
‘Targets enableus to show how
good we are’
4
This Annual Report is about planting seeds for
growth and change, and I have been delighted with
the positive response within the Trust as we
develop this vital process.
Our people are learning new skills and exploring fresh,
effective ways to work together. We are devising new
systems to save time and money. We are
communicating more effectively with one another and
with the world beyond the hospital.
All these changes are happening against the backdrop
of a rigorous three-year financial recovery plan. We are
bang on target after the first year without compromising
quality of patient care – and again, Trust personnel have
responded with energy, commitment and enthusiasm.
Now we have been asked by the Strategic Health
Authority to take up a significant role as a tertiary centre
within a new Orthopaedic Network covering Shropshire
and Staffordshire as well as a large part of Wales.
This recognition of our excellence offers a tremendous
Jackie Daniel
Chief Executive
Chief Executive’s Report
opportunity to lead, to set standards and to grow; but it
also carries a responsibility for us to perform at our
peak, and to keep improving.
At the same time, we have a responsibility to the local
community where many of our employees and their
families live.
By continuing to grow and develop, we improve the lives
of our patients, of our staff and of the people in our
community. We have made tremendous strides already,
and I am confident we will continue.
‘I have beendelighted with
the positiveresponse’
5
6
The return of the MatronThe Trust appointed Chris Morris as the first Matron at
the hospital since Mary Powell retired in 1974.
This is in line with the 2000 NHS Plan’s call for “modern”
matrons. The key focus is on quality of patient care, from first
outpatient appointment to discharge.
The Matron has to be an approachable first point of contact
for patient concerns, so high visibility to patients, their relatives
and staff is crucial. She also monitors cleanliness, food and
snacks, infection control and patient stays.
The post depends on a pro-active role in encouraging and
developing good practice among nursing and associated staff.
This involves benchmarking nursing activity, and advocating
new working methods and changes where necessary.
Chris – formerly Ward Manager of Clwyd – works in close
liaison with ward managers, but is also in frequent contact
with consultants, social workers, occupational therapists, the
League of Friends, patients groups, the chaplaincy, clinical
governance, personnel and others.
Regular rounds underpin the role, and early evidence
suggests that the return of the Matron has been a popular
move among patients and staff at the hospital.
Modern Matron
Children’s care services expandThe hospital is enhancing research into muscle
conditions, including muscular dystrophy, and
contributing to a website for clinicians, patients and
managers as part of a Welsh Neuromuscular network.
Collaborative research into McArdle’s disease, a metabolic
muscle disorder, is being carried out with Dr Greg Whyte and
his team of British Olympics sports scientists.
Professor Caroline Sewry is collaborating as part of an
international team researching the gene that causes central
core disease and other congenital myopathies.
The fortnightly muscle clinic has been increased in frequency
to at least weekly and a new clinic established at The
Children’s Hospital, Birmingham. A family care officer funded
by the Muscular Dystrophy Campaign attends clinic sessions.
The League of Friends donated a portable Bi-Pap machine to
help children with muscular dystrophy-related breathing
difficulties, and it saved the life of a young man with
muscular dystrophy almost immediately.
All children’s club foot treatment now employs the Ponseti
method. Developed by Mr Nigel Kiely. This combines plaster,
manipulaton and care.
Paediatrics
New Matron Chris Morris
on her rounds...
...and her predecessor
Mary Powell is interviewed
for BBC regional news.
7
who learn to manage fractures, neurological disease and
other conditions are less likely to fall. Numbers of falls have
remained constant, despite the unit’s increase in workload.
Occupational Therapists Claire Towers and Rosy Davidson
have worked on research on wards and on benchmarking
exercises comparing the Trust with colleagues at Luton and
Dunstable. This won the Chairman’s Award for Quality.
The unit’s success is reflected in the enthusiastic support of
GPs and district nurses, attendance figures at sessions, and
the number of beds freed up.
The Day Hospital works closely with Sheldon Ward, a 30-bed
unit for patients with movement difficulties; many have
osteoporosis or Padgett’s, for example, and their treatment
is led by Dr Mike Davie. Dr Ho works on palliative and
rehabilitation care.
Sheldon tends to treat many older patients. As with the Day
Hospital, its work is in line with the National Service
Framework criteria on age discrimination. Clinical need, not
age, is the guiding principle.
The ward receives good feedback from the community for its
personal, specialised service and the level of care and
motivation exhibited by staff. Unusually for this type of ward,
recruitment is not a problem.
Imaginative approaches to freeing bedsOccupational therapists and physiotherapists have
joined the multi-disciplinary team to work alongside
clinicians, HCAs and other therapists at the Day
Hospital, led by Dr Shu Ho.
A Parkinson’s group, relaxation therapy and horticulture have
been added to the wide range of sessions offered at the unit.
These include T’ai Chi, manicure and massage. The use of
innovative and complementary activities makes a big
difference in enabling patients with movement problems to
continue to live at home. The Day Hospital also carries out
rehabilitation and preparation for discharge.
The Rapid Response team can be called in by social services
as well as by Primary Care services, and helps deal with crises
in the home, often removing the need for a patient to be
admitted. Three free days in a local nursing home bed are
available as a stop-gap measure. Initial audits showed that
62% of patients seen were able to stay at home, 20% were
transferred to care homes and only 5% needed hospital
admittance.
Preventing and understanding falls is an important – even life-
saving – area in the day hospital and home visits. Patients
Day Hospital/Rapid Response/Sheldon Ward
Did You Know?The Pharmacy stocks upto 6,000 drug lines.
8
Midlands Centre for Spinal Injuries
Life-long treatment unit continues to set standardsThe centre has offered the ultimate in patient-centred
care since long before the phrase was generally
adopted by health administrators.
This year saw 394 patients treated, with a higher than usual
number of children as inpatients. In the last 20 years the
population of patients the Centre is responsible for has
increased to about 3,300 (three times the size of the
population in 1983). The centre continues the difficult job of
providing effective, holistic treatment for its patients without
increasing resources.
Three home and community liaison professionals based at
the centre run a 24-hour “phone-back” advice service which
provides a vital link with patients, their family/carers,
community nurses and other hospitals.
A new Consultant, Mr A Osman, has been appointed to join
Mr W S El Masry and Dr D J Short.
Mr El Masry, lead clinician, won the International Spinal Cord
Society’s annual gold medal for services to the advancement
of care of individuals with spinal cord injuries. The Department
of Health invited Mr El Masry to join the National Service
Framework for Long Term Conditions as a member of the
External Reference Group.
The centre’s national and international reputation is reflected in
the number of students, doctors and nurses who have visited
during the year, some from the UK, Japan, Greece, South
Africa, Bangladesh, Austria, Belgium, Nigeria, The Philippines
and the USA.
It has also continued to contribute to the literature of spinal
injuries treatment.
Dr Short continues to contribute as a member of the
International Spinal Research Trust. She was elected
Executive Member of the British Society of Rehabilitation
Medicine.
The courtyards which were planted out by the League of
Friends have flourished during the year, enhancing the
environment for staff, patients and their families. The unit was
built solely on charitable contributions, and the continuing
work of the voluntary sector is greatly appreciated.
Sister Di Hassall, celebrating
25 years at the hospital,
and patient Cecil Atkinson
chat outside the Unit.
9
Did You Know?The average in-patientstay is six days.
Specialist Nurses
New roles keep senior nurses intouch with patient care
Nursing is moving into more sophisticated areas, with
specialist and consultant nurses increasingly supporting
doctors’ workload. At the same time, Health Care
Assistants and other ancillary staff are taking on more
of the less-skilled work traditionally carried out by
nurses.
The Trust has employed 11 nurse specialists and two therapy
specialist practitioners. In addition, two consultant nurses –
Nicki Bellinger for Critical Care and Alison Lamb for Spinal
Injuries – are both consistently pushing boundaries for nurses
and promoting excellence in practice.
One of the “nurse-plus” appointments at the Trust is
Orthopaedic Nurse Specialist Mark Crook in the Hand and
Upper Limb Unit.
His role includes pre- and post-operative scoring of patients,
assisting in theatre, giving joint injections in clinic and handling
patient follow-ups – including annual reviews for shoulder
replacement cases.
He is also involved in the Trust’s work on clinical effectiveness,
patient information and care pathways, and is looking into
developing further nurse-led clinics.
Mark’s previous post was an orthopaedic charge nurse at the
Royal Shrewsbury Hospital. His job at the RJAH has enabled
him to return to clinical work with extra responsibility, an
option only recently opened to nurses.
Kate Jenner, Arthroplasty Nurse Practitioner – one of the
Trust’s specialised nurses.
10
Improving Norwegian children’s walkingFour Norwegian children aged between seven and
14 spent several weeks in Alice Ward for a range of
treatments related to their cerebral palsy.
After gait analysis at ORLAU, they received corrective surgery
and intensive physiotherapy to improve their walking pattern.
Parents and children worked in partnership with staff to get
over their initial anxieties and make the stay a positive
experience.
During their admission a surprising number of Norwegian
speakers emerged from the Trust to visit the group, whilst
both staff and children learned a little of each others language
and culture.
The multi-disciplinary team at the RJAH liaised with
Norwegian clinicians and physiotherapists, often by e-mail, to
ensure effective continuity of care once the children were
discharged.
A working party from Norway also visited the trust, with a view
to setting up their own facility for treatment.
Overseas Patients
Leading the way in microwave treatmentThe cancer unit, led by Consultant Paul Cool, pioneered
the use of microwaves to treat osteoid osteoma, a
benign but very painful bone tumour found usually in
adolescents.
As an alternative to prolonged use of anti-inflammatories or
open surgery, the microwave is quick, precise and effective. It
is delivered by an insulated electrode needle with a cool tip
while the patient is under a CT scanner. Radiologists Dr Victor
Pullicino and Dr Bernard Tinns help Mr Cool with the technique.
The treatment was used on 43 patients from as far afield as
Barbados and Italy. The unit is the main UK centre for this
technique, and is looking into broadening its use to other
tumours, sometimes with an “umbrella” tip to treat wider areas.
The RJAH unit is small, since musculo-skeletal tumours tend
to be uncommon, but it has close links with other centres,
including the Royal Orthopaedic in Birmingham and the
Christie in Manchester.
The number of patients attending David Williams’ tumour
clinic was 586, which was 39 up on the previous year. The
total attending clinics was 973.
Cancer Unit
Mr Cool and colleagues
working on the innovative
microwave treatment.
11
Did You Know?Occupational Therapylent equipment to 1,290patients, and 1,410patients returned theirloan items.
Occupational Therapy Physiotherapy
Busy therapists helping to clearbed spaceOccupational Therapy (OT) saw a 9% increase in
face-to-face and initial patient contacts year-on-year.
Patient audits indicate that pre-operative OT clinics are very
helpful in giving people techniques and equipment to carry out
tasks at home and to reduce pain. Issuing equipment before
surgery saves time and can free up bed space, as patients
are better prepared to cope at home. There is a strong case
for even earlier OT involvement.
Weekend availability of staff was introduced, speeding patient
discharge and freeing up beds. More bed-saving activity has
been carried out through falls information, with the £500
Chairman’s Prize reflecting the quality of project leader Rosy
Davidson’s work.
A successful Mobility Day, supported by specialist vehicle
manufacturers, was held at the Spinal Injuries Unit.
The department was fully staffed, apart from a recruitment
hold at the end of the year due to financial restrictions. Jobs
at the unit are well sought-after, despite a national OT staff
shortage.
Joint project highlights physiochangesThe unit treated 2,584 outpatients, 6,213 inpatients, 209
mothers and babies in the maternity unit and carried
out 1,145 specialist outpatient assessments.
Another Extended Scope Practitioner was appointed.
These specialist physiotherapists see patients in pre- and
post-operative clinics, and represent one of the new
approaches to to patient care promoted by the
NHS plan. A patient postal survey, with a very good response
rate of 97%, indicated a high degree of satisfaction with this
new service.
Another innovation is our involvement in the formation of a
jointly based project with Wrexham. The multi-disciplinary
team includes RJAH Physiotherapy and Orthotic staff and
aims to improve the patient’s journey for Welsh orthopaedic
clients.
Department staff accompanied spinally injured patients to
Calvert Trust Outward Bound Centre in Keswick and to the
inter-unit games. Up against a dozen other teams – some
with up to 15 contestants – the three RJAH contestants came
a creditable seventh.
Physiotherapy and Sports
Injuries staff get in training for a
charity fund-raiser.
12
Global rostering boosts theatresA change in working practices with enhanced flexibility
and teamwork has been the happy result of Theatres’
success in turning round an overspend on pay.
Manager Chris Neen, appointed in January, introduced a
global rostering system. If a team is fully staffed during a quiet
period, personnel would traditionally have been asked to take
a few days’ annual leave. Now, the team leader checks
whether “spare” hands are needed to cover busy schedules
and/or staff shortages in other teams.
This liaison and co-operation has boosted productivity,
enhanced morale and encouraged multi-specialisation among
the teams.
Extra staff have been appointed, and were selected according
to their multi-skills abilities, so have helped eliminate the need
to employ expensive agency staff. Mr Sudheer Karlakki joined
the unit as an additional arthroplasty surgeon.
The total number of operations was up from 6,922 in
2001-2 to 7,126. There were 294 cancellations – 3.96% –
of which only 35 were within the hospital’s control. All were
readmitted within 28 days. Other cancellations were due to
patients being unfit for surgery through illness, failure to
turn up, etc.
Theatres
Better working lives for our staffThe Improving Working Lives (IWL) Standard is an
important initiative covering childcare, flexible working
and other staff-related issues. The Trust achieved the
NHS “Practice” status in IWL and a Work-life Balance
Co-ordinator has been appointed to push towards
“Practice Plus”.
Funds from the Workforce Confederation have allowed work
to continue on the creche, due to open in autumn 2003.
The Trust has been working closely with unions and
hospital representatives on Agenda For Change, the new
pay and reward structure scheduled for October 2004
implementation.
The staff survey was completed and gives an interesting
snapshot of the Trust and its people. For example, 37% of
employees have worked at the hospital for over 11 years, and
91% would be happy for their families to be treated at the
RJAH. More information is available from the HR Department.
Communications are being improved within the Trust, with
more information being exchanged via e-mail and the Trust
Intranet. Joint Issues, a regular staff newsletter, was launched.
Occupational Health services are available to all employees.
Human Resources
The Trust operates an equal opportunities policy whichopposes all forms of unlawfulor unfair discrimination,including those on grounds ofdisability.
This policy covers all aspects ofemployment including recruitment,selection, training, promotion andcareer management. In addition,the Trust’s sickness absence policyprovides guidelines and proceduresfor managing circumstances wherean employee is unlikely to be ableto return to usual duties; for example, where an employee hasbecome disabled.
A childcare open day held at
Denbigh’s offered advice and
guidance to Trust employees.
13
Did You Know?The hospital has ultrasound, CT, MRIand nuclear medicine scanners, six X-raytables, two mobile X-raymachines and three intensifiers for use during surgery.
More hands for busy teamA new consultant radiologist was appointed to this busy
department, where activity increased by 11.9%.
A special investigations room using low-radiation digital
technology was opened, and Pacs Port, a new plug-in
scanning system, has been installed in theatre.
Radiology
10 years of excellenceThe Orthotics Department celebrated its 10th
anniversary with an open day.
Private companies currently supply 80% of UK orthoses –
splints, calipers and other patient movement aids. However,
the hospital has its own in-house design and manufacturing
facility which has become a major world centre of excellence.
Seven orthotists, six administrators and eight technicians run
the department, one of the UK’s largest, supplying Shropshire,
Wrexham and Powys patients as well as the RJAH. The
department works closely with ORLAU.
Orthotics
Maximising value from drugsNew drugs can save money, by eliminating the need for
an operation, for example, but clinicians need clear
information on their effectiveness.
The Pharmacy has developed a New Product Request system
to support clinicians with informed, evidence-based
assessments of emerging drug treatments and
recommendations on their use.
This system reflects a more planned and co-ordinated use of
drugs under new Director of Pharmacy Mike Daly.
The hospital has to face a continual increase in the drugs
budget, not all of it related to increased activity. To help
address this, the budget is starting to be devolved to
departments, while the Pharmacy develops an increasingly
pro-active and strategic role.
To improve working conditions for the Pharmacy’s 14
personnel, much-needed improvements to the fabric and
layout of the department, including air conditioning, are
under way.
The department handled over 72,000 transactions during the
year, ranging from quick counter requests to telephone calls
that sometimes take hours to resolve.
Pharmacy
Senior Pharmacy Technician
Wendy Mayne at work.
Voluntary Services
Pool Appeal nears £1.3m targetRaising funds for a new therapeutic swimming pool has
helped make the year busier than ever for the League of
Friends. The £1.3 million target is in sight, boosted by a
£403,000 donation from the estate of Mr Samuel Pennill.
General fund-raising for medical, amenity and research
projects continues through the shop, coffee shop and fete.
Pledges include £100,000 for the Torch Appeal.
Members also provide the help desk and trolley services, the
latter with support from local WIs and WRVS volunteers. The
100-plus members of the Flower Guild keep the wards and
departments looking bright and colourful, while the Hospital
Library volunteers provide much-needed reading material for
patients.
Red Cross volunteers visit weekly with their Therapeutic Care
Service, and the Disabled Swimming Club is giving design
advice to the new pool project.
The hospital is fortunate to have so many supporters and
volunteers with such a friendly and helpful approach to
enhancing the patient experience at “The Orthopaedic.”
14
An architect’s impression
of the new facility for
children which will be funded
by the Torch Appeal
Flower Guild Organising
Secretary Daphne Williams
tends one of the gardens.
World-class new gait analysissystem The unit has a new, world-leading gait analysis system
costing £80,000 which uses a million-pixel, infra-red
camera system and markers to assess patients’ walking
cycles and thephysical forces involved.
More than 320 patients were analysed during the year, with
460 finished rehabilitation episodes. In addition, the unit gave
advice to clinicians from Britain, the rest of Europe and Israel.
ORLAU’s long-standing multi-disciplinary approach, plus its
continuing combination of hands-on treatment and research,
has kept it going for 27 years. However, most patients
are children, and they need a dedicated centre to offer
assessments, parent resources, viewing facilities, a quiet
room, internet access and other facilities to make the most of
the expertise and commitment available at the Trust.
The Torch Appeal to build such a treatment centre for children
made great progress throughout the year, with fund-raising
activities taking place at the Trust and beyond. The projected
cost runs well into seven figures, and at the year end, the fund
stood at £495,000.
ORLAU/Torch Appeal
15
The Annual Research Days for
professionals and the public
gave lay people a chance to
conduct simulated surgery.
Graham Smith is pictured
supervising an “arthroscopy.”
£750,000 grant for cell growthThe OsCell team has won a £750,000 Medical Research
Council grant. This is a first for the Trust, which will
be working with Birmingham University to lead a
multi-centred trial of its technique of using lab-grown cell
tissue to repair damaged cartilage in joints. The team’s
partners at Keele University are administering the trial.
The Trust is also involved in a study of new approaches to
treating rheumatoid arthritis.
ORLAU received a £82,870 grant from Action Research
for a three-year study into the use of heat pads and orthoses
– mechanical devices – to correct joint contractures. By
stretching joints more effectively, it is hoped that this treatment
will improve movement for cerebral palsy patients.
The Charles Salt Centre for Human Metabolism carried out
various bone-related research projects, including the relationship
between men’s body mass and osteoporosis, fracture among
patients taking corticosteroids, continuing work on osteoporosis
detected by peripheral scanning, and studies into Coeliac
disease, stroke, Paget’s disease and rickets in Nigeria.
Research teams publish their own annual reports – contact
the Arthritis Research Centre at the Trust for more information.
Research Life-long Learning
Beating targets for trainingThe NHS requirement for all non-professional hospital
staff to receive NVQ training is well on track at the
Trust, with 53 Level One successes, against a target
of 47.
All cleaners have completed NVQ Level 1 in housekeeping,
including some customer care elements.
These successes are despite the lack of allocated study time,
reflecting tremendous credit on the staff, and on the invaluable
work of the dedicated assessors and verifiers.
Some Health Care Assistants are taking NVQ Level 2. Level 3
allows entry into nurse training and other professional
qualifications.
The Workforce Confederation funds a training administrator at
the Trust (Josy Clare, pictured below with HCA Collette
Powell). This part-time role has now become full-time.
Did You Know?The Trust is compliantwith NHS guidelineson providing single-sex wards
16
Computers enhance flow ofinformationThe library continues to expand its services to all staff
and students based at the Trust.
Siobahn Whitby took up the newly-created post of electronic
resources assistant librarian in July 2002. This has led to the
development of library pages on the Trust Intranet, giving
information on services, and links to Internet-based resources.
A structured training programme for individuals or small
groups in the use of databases for literature searching has
also been rolled out to wards and departments.
The library management system for registering users
and recording book loans was fully computerised in
February 2003.
The two part-time library assistants both successfully
completed an NVQ Level 3 in information and library services.
Francis Costello Library,Institute of Orthopaedics
Marie Carter, Health
Services Librarian,
at work on the computer.
Patient Access and Healthcarerecords
IT eases load, but paper still prevailsComputer-based information is making an increasing
impact, but the hospital still generates a lot of paper.
Appointments staff sent out 1,500 letters a week, and 60
metres of files – the usual annual increase – were added to
the case note library. This represents 14,000 sets of notes.
The library has 800m of shelved notes, the earliest dating
back to 1918.
Manager Preston Fletcher and staff in the waiting list office are
using the Trust’s computerised Information Management
System (TIMS) to streamline waiting list procedures and
prioritise operating lists. It makes patient and waiting time
information available in a multi-sortable format on PC, saving
busy staff the task of wading through bulky print-outs. It is
helping the Trust implement the national First and Fast project
– clinically prioritised waiting list management.
The Health Care Records department covers over 50
personnel – 30 of them secretaries – in all departments apart
from The Midlands Centre for Spinal Injuries and the Charles
Salt Research Centre. Duties include booking appointments
and operations, arranging admissions, running the case note
library, clinical coding and outpatients’ reception.
17
Green all the wayThe Trust scored a top “green” rating for all national
patient environment targets. These include food,
estates, cleanliness, privacy and dignity.
The catering service served up around 1,000 meals a day
throughout the year. The NHS Better Hospital Food measures
include three chef’s specials a day for patients, a two-course
evening meal, snack services and ward kitchens.
Hotel Services
Keeping up tradition of learningAround 100 student nurses passed through the Trust.
Most of them are from Staffordshire University on 12-week
placements, taking degree and diploma courses in
orthopaedics, rheumatology and spinal injuries.
The Clinical Placement Facilitator, a part-time post about to
become full-time, supports students and mentors, liaises with
12 educational link nurses at the hospital and handles documentation.
Clinical Placement Facilitator
New 24-bed Ercall Ward opensThe new 24-bed Ercall ward opened in a demountable
building next to Denbigh’s Restaurant. The new unit
complies with NHS guidelines on accommodating male
and female patients.
The former premises were converted to house a quiet/prayer
room, a new PALS office for patient liaison services, and
stores.
The Charles Salt laboratory was upgraded with new floor,
benches, fume cupboards and other equipment, improving
the working environment for researchers.
New cabling and switchgear was installed in Phase 2 of
the Trust’s major upgrade to the electrical infrastructure.
Work continued upgrading the fire alarm system to achieve
compliance by 2004.
Other activities included roofing repairs, refurbishing
bathrooms for single-sex provision on Kenyon Ward, and on
the new nursery, due to open in 2003. Design and identifying
capital in partnership with the League of Friends for the
planned new hydrotherapy pool also took place.
Estates
Trust domestic staff celebrate a
100% pass rate in NVQ Level 1
Housekeeping.
Did You Know?Denbigh’s, the Trustrestaurant, made£299,880 grossprofit – £16,500above target – to fundbetter food for patients.
18
Sharing is caringClinical audit is central to the Trust’s aim of being at the
cutting edge of quality improvement in the region’s
orthopaedic care.
The recent CHI Report criticised a shortage of multi-
disciplinary audits at the Trust, with little inter-departmental
sharing of results.
Quarterly multi-disciplinary meetings have been established,
and these include presentations of audits, plus short lectures
and tutorials relating to clinical audit.
Many health workers, especially doctors, are cynical of the
usefulness of clinical audit. The new structure is designed to
re-invigorate staff and increase involvement.
Already, more audits are taking place and attendance is grow-
ing at the new quarterly audit meetings.
Clinical Audit
The right information for the rightpeople at the right timeComputerised systems developed at the Trust are
making it quicker and easier for appropriate
professionals to have instant access to electronic
records, including case notes, waiting list information
and test results.
This process is covered by “information governance” – the
laws, guidelines and activities that ensure information is
correct, is given to the right people (and only the right people)
and is available whenever it is needed.
The patient’s medical history can be built up from different,
linked computer systems. By using the NHS number,
information can be shared without the patient’s name and
address being revealed.
The Data Quality Manager checks and improves patient
information, and every NHS organisation has a “Caldicott
Guardian” policing confidentiality.
The new Information Governance Group, reporting to the Trust
Board, ensures that the hospital’s excellent IT record is
matched by the quality, availability and security of its information.
Information Governance
Matron Chris Morris and IT
specialist Mike Nowell with a
PC displaying Electronic Patient
Records, a computer aid
helping to achieve integrated
care pathways for patients.
19
Partners with our patientsIn line with the Government’s guidelines on clinical
governance – continuous improvement of quality and
standards – the Trust is creating genuine, on-going
partnerships between patients and staff.
The Trust received 50 written complaints. All were
acknowledged within two working days and received a full
written response from the Chief Executive. Changes in
practice have taken place where appropriate – usually
involving improved communications to the patient. Three
requests for Independent Review were received and,
following consideration by the Complaints Convenor, these
were referred back to the Trust for further action. As well as
gifts and messages to individual wards and departments, 331
comment cards and letters, mostly very complimentary, were
recorded.
The Trust revisited risk management and health and safety
issues, advertising for a new full-time H&S officer to be
appointed in 2003-4.
In the spirit of NHS reforms, a dedicated, independent PAL
(Patient advice and liaison) needs to be appointed. In the
meantime, a highly visible PALS office with adjacent
bereavement/prayer room has been completed.
Patient and Public InvolvementInfection Control
Using the web to beat infectionThe Trust has taken part in a two-year, Shropshire-wide
infection control project which will make 500 pages of
standardised policies and information available on the
hospital intranet.
The operating theatre design includes specialised
ventilation.The infection control nurse checks all hip and knee
replacement patients for signs of infection while they are in
hospital.
The hospital’s infection rates were surveyed this year, and
showed that two out of 475 knee replacements and five out of
567 hip replacements became infected while in hospital. This
is well below the national figures, partly because the Trust
handles only a few trauma cases.
However, improvements to administrative procedures on
infection control risks and audit follow-up of patients after
discharge from hospital are a major priority at the Trust.
Did You Know?The Trust’s six part-timechaplains, including aWelsh speaker, offerspritual support andguidance to patients,families and staff
20
Trauma & Orthopaedics
Arthroplasty
Foot & Ankle
Paediatrics
Spinal Surgery
Upper Limb
Other
SUB TOTAL
General Medicine
Spinal Injuries
Rheumatology
Care for the Elderly
Plastics
Anaesthetics
Radiology
Paediatrics
Casualty
TOTAL
Clinical Activity 2002/3
2,803
270
601
703
1,597
1,655
7,629
1,007
499
467
234
65
175
26
5
–
10,107
10,771
1,866
4,073
3,162
9,419
4,101
33,392
8,863
1,640
4,038
4,519
151
1,193
–
330
3,330
57,456
OutpatientsInpatients/DaycasesSpeciality
Ludlow Ward
Private patient activity generated £2,580,865 compared to £2,457,874 in 2001/2, a £122,991 increase.
Most of this, 61%, was derived from arthroplasty procedures,including 424 lower limb referrals and 184 hip replacements. Atotal of 910 patients were seen by consultants, 390 of themaged over 60.
The unit is talking to private investors and Trust managersabout possible expansion to handle an anticipated increase in demand.
English Welsh
TotalEnglish onlyWelsh only
Waiting list times for routine activity are set by the Department of Health inEngland and by the Welsh Assembly in Wales. The Trust met all its waitinglist targets for 2002-3. English outpatient maximum waiting time wasreduced from 26 to 21 weeks.
12 months18 months
2,9401,6851,255
21 weeks18 months
3,7901,9691,821
At 31/3/03, the numbers on the waiting list were:
92% of outpatients were seen within 30 minutes
At 31/3/02, the numbers on the waiting list were:
Inpatients/Daycases OutpatientsWaiting lists
TotalEnglish onlyWelsh only
2,4721,0041,468
2,8711,1271,744
The Trust published itsLocal Health Delivery Plan2003/6.
This three-year strategyexplains how the hospitalintends to help meet localhealth needs against thebackground of NHS objectives for healthcarenationally.
The Trust runs an annual self-assessment against NHS Controls AssuranceStandards.
This identifies risks and ways to control them, andmonitors the effectiveness ofthose controls.
It covers 21 wide-rangingareas of activity, includingtransport, financial management, waste, buildings, security and catering.
21
Did You Know?8,238 consultantepisodes were recorded –an 8% rise on last year
Contracts
Where the work comes from
SHROPSHIRE45.28%
NORTH WALES22.37%
MID WALES11.02%
SOUTH CHESHIRE3.28%
WEST MIDLANDS SPINES8.73%
OTHER9.32%
BIRMINGHAM PCT 0.20%DUDLEY 0.51%HEREFORD 0.60%NORTH STAFFS 2.45%NORTH STAFFS TRUST 0.68%READING PCT 0.28%SOUTH STAFFS 1.31%SEFTON 0.97%WEST PENNINE 0.18%WIRRAL 0.25%WORCESTER 0.57%CONTRACTS UNDER £50K 1.32%
As a NHS Trust, the hospital has three statutory duties toachieve. These are shown in the table below.
We are also measured on how many bills we pay within 30 days – we achieved98% in 2002/03.
The hospital generated over £38 million in income in 2002/03, an increase of 9%on the previous year. Of this income, £22 million, or 62% relates to pay costs. Forevery pound spent the breakdown is as follows:
Nursing Costs
Medical Staff
Therapy and Scientific staff
Administrative and Clerical staff
Healthcare assistants/Support staff
Senior and general managers
Clinical supplies (Drugs, Dressings, Implants)
Premises costs (Fuel, Rates, Maintenance, Telephones, Postage)
Depreciation
General supplies (Food, Linen, Uniforms)
To develop the hospital facilities, the Trust received £2 million this year for CapitalExpenditure, ie buildings and equipment. In 2002/03 the Trust used theseresources to make improvements to the hospital environment. We are also indebted to the high level of donations made into our charitable funds each yearwhich further enables us to improve the facilities for patients, staff and visitors.As a hospital we also benefit from the considerable fund raising undertaken by volunteers.
17p
17p
12p
8p
6p
3p
22p
7p
5p
3p
FinancialPerformance
2002/03Shropshire
OATS (out of area treatment)
CRES (cash-releasing efficiency savings)
£,000s
766
363
340
Forecast Deficit per recovery plan
Shropshire OATS (NR – non-recurring)
RJAH Additional (NR)
PCT Support (NR)
STHA Support (NR)
Year End position
£,000s
1,700
(250)
(208)
(200)
(250)
792
Balance Income & Expenditure
Achieve External Financing Limit
Achieve Capital Absorption Rate
22
STATUTORY DUTY ACHIEVED
£,000s
+792 (overspend)
(721)
6%
TARGET
£,000s
Balance
(721)
6%
CAUSE OF THE DEFICIT AND FUTURE BREAKEVEN
The 2002/03 SaFF resulted in a drop in income in real terms as follow
Additional unfunded cost pressures, including the withdrawal of funding for non-payinflation by host purchases of £110,00 and the disproportionate PAMS pay awardbrought the total CIP to 2.0m.
Additional in year cost pressures etc. led to realisation that the Trust would notachieve its target and the subsequent production of a recovery plan, which forecasta year end deficit of £1.7m.
Following this further action was taken to reduce the deficit as below.
The plan in 2003/04 is to receive work from other commissioners includingCountess of Chester Hospital totalling £1.8m with the recovery timescale of twoyears. The trust is on target to achieve a surplus in 2003/04 of £200,000 and£600,000 in 2004/05, and therefore recovering the deficit of £792,000.
Cash brokerage was received of £2.4m to enable the Trust to comply with the Better Payment Practice Code, if this had not been received note 7.1 would haveperformance figures of approximately 80%.
The Cost Improvement Programme provides continuous monitoring and demonstration of Value for Money activities throughout the Trust.
Income from activities:Continuing operationsOther operating income
Operating expenses:Continuing operations
Operating surplusContinuing operations
Exceptional Gain: on write-out of clinical negligence provisions
Exceptional Loss: on write-out of clinical negligence debtors
Cost of fundamental Reorganisation/reconstructingProfit (loss) on disposal of fixed assets
Surplus before interest
Interest receivableInterest payable
SURPLUS FOR THE FINANCIAL YEARPublic dividend capital dividendspayable
RETAIN SURPLUS (DEFICIT)FOR THE YEAR
INCOME & EXPENDITURE ACCOUNT BALANCE SHEET Financial Report
2002/03£,000s
32,7025,569
(37,482)
789
0
0
00
789
280
817
(1,609)
(792)
2001/02£,000s
31,1274,427
(34,102)
1,452
2,166
(2,166)
00
1,452
320
1,484
(1,475)
9
31.3.03£,000s
034,89934,899
1,4343,219
1104,763
(5,388)
(625)
34,274
0
(1,376)
32,907
22,1646,6155,535
(1,407)
32,907
31.3.02£,000s
030,59030,590
1,3412,078
383,457
(2,510)
947
31,537
01
(25)
31,512
22,8133,2045,104
391
31,512
Fixed assetsIntangible assetsTangible assets
Current assetsStocksDebtors Cash at bank and in hand
CREDITORS: Amounts falling due within one year
Net current assets/(Liabilities)
Total assets less current liabilities creditors:Amounts falling due after more thanone yearPROVISIONS FOR LIABILITIES ANDCHARGES
TOTAL ASSETS EMPLOYED
FINANCED BY:CAPITAL AND RESERVESPublic dividend capitalRevaluation reserveDonation reserveIncome and expenditure reserve
TOTAL CAPITAL AND RESERVE
23
OPERATING ACTIVITIESNet cash inflow from operating activities Returns on Investments andServicing of FinanceInterest receivedInterest paidInterest element of financial leases
Net cash (outflow) from returns oninvestments and servicing of finance
CAPITAL EXPENDITUREPayments to acquire fixed assetsReceipts from sale of fixed assets(Payments to acquire)/Receipts from sale ofintangible assets
Net cash (outflow) from capital expenditure
DIVIDENDS PAID
Net cash inflow (outflow) beforeManagement of liquid resources andfinancing
FINANCINGGovernment loans repaid – Long term
Net cash inflow/(outflow) from financing
Increase (decrease) in cash
CASH FLOW STATEMENT STATEMENT OF RECOGNISED GAINS AND LOSSES
2002/03£,000s
5,174
2800
28
(2,872)0
0
(2,872)
(1,609)
721
(649)
72
2001/02£,000s
1,611
3200
32
(1,753)0
0
(1,753)
(1,475)
(1,585)
1,585
0
31.3.03£,000s
817
4,105
49
(312)
0
4,659(1,006)
3,653
31.3.02£,000s
1,484
305
31
(450)
0
1,3700
1,370
Surplus (deficit) for the financial year beforedividend payments
Unrealised surplus (deficit) on fixed asset re-valuations/indexation
Increases in the donation reserveDue to receipt of donated assets
Change in donation reserve in depreciation,of profit/loss on disposal of donated assets
Additions/reductions in “other reserves”
Total recognised gains and losses forthe financial year (prior period adjustment)
Total Gains and losses recognised in the financial year
Financial Report
24
Financial ReportDETAILS OF REMUNERATION PAID TO DIRECTORS 2002/03
Salary (bands of £5000)
£,000s
17
21
2
91
18
5
72
6
5
50
Bolderston, M.JChairman
Buckley, S Director of Operations
Cubbon, JChief Executive (terminated April 2002)
Daniel, JChief Executive
Dixey, JMedical Director
Jones, P.WNon-executive Director
Robinson, ADirector of Finance
Vint, ANon-executive Director
Woodward, NNon-executive Director
Plant, CEstates Director
Name and Title Age
59
43
39
47
57
43
41
55
48
Other Remuneration(bands of £5000)
£,000s
–
–
–
–
–
–
–
–
–
–
Golden Hello/compensationfor loss of office
£,000s
–
–
–
–
–
–
–
–
–
–
Benefit in kind£,000s
–
–
–
–
–
–
–
–
–
–
Real increase in pension atage 60(bands of £2,500)
£,000s
–
–
–
20
2
_
7
_
_
15
Total accrued pension atage 60 at 31/3/2003
(bands of £5,000) £,000s
_
_
_
20
23
_
9
_
_
15
Benefits in kind include cars.
The Trust has complied with the Chief Executive of the NHS “Executives” letter of April2002 regarding NHS Managers pay in 2002/03.
During the year none of the Board members or members of the management staff or parties related to them has undertaken any material transactions with The Robert Jones& Agnes Hunt Orthopaedic and District Hospital NHS Trust
Management Costs2002/03 2001/02
£,000s % ofincome £,000s % of
income
Total trust income
Management costs
38,271
1,254 3.28%
35,584
1,306 3.67%
25
Better Payment Code - Measure of Compliance
The NHS Executive requires that Trusts pay their non NHS trade creditors in accordance with the CBI prompt payment code and Government Accounting rules.The target is to pay non NHS trade creditors within 30 days of receipt of goods or avalid invoice (whichever is the later) unless other payment terms have been agreedwith the supplier. The measure of compliance is:
The Trust has received no complaints regarding failure to pay on time, and hasincurred no charges under The Late Payment of Commercial Debts (Interest) Act 1998.
Signed: Jackie Daniel, Chief Executive Date: August 2003
Signed: A. Robinson, Finance Director Date: August 2003
AUDITORS REPORT ON THE SUMMARY FINANCIAL STATEMENTS
I have examined the summary financial statements set out on pages 23 to 25.
Respective responsibilities of directors and auditorsThe directors are responsible for preparing the Annual Report. My responsibility is to report to you my opinion on the consistency of the summary financial statementswith the statutory financial statements. l also read the other information containedin the Annual Report and consider the implications for my report if I become awareof any misstatements or material inconsistencies with the summary financial statements.
Financial Report Basis of opinionI conducted my work in accordance with Bulletin 1999/6 “The auditor’s statement onthe summary financial statements” issued by the Auditing Practices Board for use inthe United Kingdom.
In forming our opinion, I have considered the adequacy of the disclosures made onpage 22 of the financial statements concerning the uncertainty as to the ability ofthe Trust to meet its statutory financial obligations and consequently on its ability tocontinue to operate in its current configuration. In view of the significance of thisuncertainty I consider that it should be drawn to your attention but our opinion is notqualified in this respect.
OpinionIn my opinion the summary financial statements are consistent with the full financialstatements of the Trust for the year ended 31st March 2003 on which we haveissued an unqualified opinion.
Signed: Delyth MorrisDate: August 20031 Friars Gate, 2nd Floor,1011 Stratford Road, Solihull, B90 4EB
The Board acknowledges and accepts its responsibility for maintaining a sound system of internal control including risk management, and for reviewing its effectiveness.
As part of the NHS Controls Assurance Project, I as Chief Executive confirm that theyear ending 31st March 2003, and in accordance with NHS Executive circulars HSC2001/00 and HSC 1999/123 and supporting guidance, the Board has reviewed andendorsed an action plan resulting from an organisation wide self assessment againstrelevant risk management and organisational control standards produced by the NHSExecutive. The Board will oversee implementation of the action plan.
Signed: Jackie Daniel, Chief Executive Date: August 2003
STATEMENT OF BETTER PAYMENT POLICY
2002/3 2001/2
Number £,000s £,000s
25,025 14,157 11,236
24,462 13,567 9,088
97.75% 95.83% 80.88%
26
Total bills paid
Total bills paid within target
Percentage of bills paid within target
The Board is accountable for internal control. As Accountable Officer, and ChiefExecutive Officer of thisBoard, I have responsibility for maintaining a sound systemof internal control that supports the achievement of the organisation's objectives,and for reviewing its effectiveness. The system of internal control is designed tomanage rather than eliminate the risk of failure to achieve these objectives; it cantherefore only provide reasonable and not absolute assurance of effectiveness.
The system of internal control is based on an ongoing risk management processdesigned to identify the principal risks to the achievement of the organisation'sobjectives; to evaluate the nature and extent of those risks; and to manage themefficiently, effectively and economically. The system of internal control isunderpinned by compliance with the requirements of the core Controls Assurancestandards:
● Governance● Financial Management● Risk Management
As Accountable Officer, I also have responsibility for reviewing the effectiveness ofthe system of internal control. My review of the effectiveness of the system of internal control has taken account of the work of the executive management teamwithin the organisation who have responsibility for the development and maintenance of the internal control framework, and of the internal auditors. I havealso taken account of comments made by external auditors and other review bodiesin their reports.
The assurance framework is being finalised and will be fully embedded during2003/04 to provide necessary evidence of an effective system of internal control.
The actions taken so far include:
● The organisation has undertaken a self-assessment exercise against the core Controls Assurance standards (Governance, Financial Management and Risk Management). An action plan has been developed and is being implemented to meet any gaps.
● The organisation has in place arrangements to monitor, as part of risk identification and management processes, compliance with other key standards,
including relevant Controls Assurance standards to identify areas of significant organisational risk.
● Identification of strategic goals and associated risks via The Local Health Delivery planning process
● A review of Risk Management committee structures and accountabilities● A presentation to the Board by Internal Audit on meeting the requirements of the
Board Assurance Agenda in March 2003.
In addition to the actions outlined above, in the coming year the Trust will
● Introduce risk awareness training for key staff and raise awareness of accountabilities and systems for the reporting and management of risk across the Trust – by Quarter 4 2003/04 (March 2004).
● Identify and evaluate the design of key controls intended to manage principal risks, underpinned by core controls assurance standards – by Quarter 3 2003/04 (December 2003).
The Robert Jones & Agnes Hunt Orthopaedic and District Hospital NHS Trust –Annual Accounts 2002/03
● Put in place arrangements for obtaining Assurance on the effectiveness of key controls across all areas of principal risk – by Quarter 3 2003/04 (December 2003).
● Identify and act on areas where there are gaps in controls and/or assurances – by Quarter 3 2003/04 (December 2003).
● Put in place plans to take corrective action where gaps have been identified in relation to principal risks – by Quarter 3 2003/04 (December 2003).
● Develop dynamic risk management arrangements including development of a 'higher level' risk register to ensure that it is well populated with risks drawn from all areas of the Trust – by Quarter 3 2003/04 (December 2003).
Signed: Jackie Daniel, Chief Executive Date: 17th July 2003
(On behalf of the board)
STATEMENT OF DIRECTOR'S RESPONSIBILITY INRESPECT OF INTERNAL CONTROL
Internal Control
27
